Source · Prevention of Future Deaths

Matilda Davis

Ref: 2026-0198 Date: 7 Apr 2026 Coroner: Deborah Sewell Area: Warwickshire Responses identified: 1 / 2 View PDF

Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.

Date 7 Apr 2026
56-day deadline 2 Jun 2026
Responses identified 1 of 2
Suicide (from 2015)

Coroner's concerns

AI summary
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.
View full coroner's concerns
Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation. In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context.  It was also noted that she was not signposted to crisis support services at that time. The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.

Responses

1 respondent
Warwickshire County Council Local Authority / Fire Service
PDF
Received

No AI summary available.

Report sections

Investigation and inquest
I conducted an inquest into the death of Matilda Rose Davis otherwise known as Matilda Rose Southhall. The inquest concluded on the 20th March 2026. Matilda died on the 3rd October 2025 at her home address of  [REDACTED]. 

The medical cause of death was confirmed as

1a) Suspension by a ligature around the neck.

I recorded a short-form conclusion of Suicide.
Circumstances of the death
On 3rd October 2025, Matilda was found deceased at her home in Stratford-upon-Avon. Earlier that day, Warwickshire Children’s Social Care had conducted an urgent safeguarding visit following concerns raised by her estranged husband regarding her mental health and the welfare of their two children. During the visit, Matilda reported experiencing emotional and psychological strain arising from relationship conflict, financial pressures, and the ongoing divorce proceedings. She also described recent episodes of head-banging behaviour and confirmed aspects of her medical history, including discontinued antidepressant medication and a current prescription for diazepam. She stated that she intended to arrange a further GP appointment. Before concluding the visit, the attending social worker and the support worker noted that Matilda’s demeanour was calm and that she expressed no suicidal ideation. Shortly after their departure, Matilda was found hanging by a ligature attached [REDACTED]. There was no evidence of forced entry. The emergency services attended, but Matilda was pronounced deceased at 16:26 hours on 3rd October 2025.

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Report details

Reference
2026-0198
Date of report
7 April 2026
Coroner
Deborah Sewell
Coroner area
Warwickshire

Responses identified

Responses identified 1 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Jun 2026.

Sent to

Warwickshire County Council – Children and Young People
Warwickshire County Council – Children with Disabilities team

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